Obsessive-Compulsive Disorder

WHAT IS OBSESSIVE-COMPULSIVE DISORDER?

Obsessive-compulsive disorder (OCD) is characterized by uncontrollable, disturbing thoughts and urges, called obsessions, that make a person feel extremely anxious.¹ Then, in response to these obsessions, the person performs repetitious behaviors, called compulsions, that temporarily relieve the anxiety. However, the obsessions soon return and the compulsions are repeated. As the disorder intensifies, this repetitious cycle becomes very disturbing to the person struggling with OCD.² The sequence of obsessions and compulsions is very time-consuming, often interferes with the person’s job, can cause relationship difficulties, and frequently causes the person to avoid feared situations in which the cycle might be triggered.

There are a number of common obsessions. Among the most frequently reported is the fear of contamination by germs, dirt, chemicals, or diseases.³ People with this obsession are often overwhelmed with thoughts of harming themselves or others, so they try to avoid coming into contact with certain surfaces, contaminated objects, dirt, or bacteria. In response to this fear, these people perform compulsions such as frequently washing their hands, changing their clothes, and avoiding dirty objects like doorknobs, shoes, and newspapers.

Repetitious uncertainty is another common obsession. This can include doubts about whether or not the person turned off the stove, made a mistake at work, or hit someone while driving. This type of obsession leads to compulsions that are extremely time-consuming. The person is rarely satisfied with the safety or perfection of his or her actions and thus must check and recheck his or her own behaviors. Examples include returning home multiple times to make sure the oven is turned off and repeatedly turning the car around to make sure the person really didn’t hit someone in the road.

Obsessions of perfection are thoughts that require the person to arrange objects perfectly or to perform tasks in a rigid, systematic fashion. Often, people with this compulsion can’t complete a task if they can’t perform every step of that task in a specific order.

Obsessions about causing harm to others lead the person to think about hurting other people, including strangers. This type of obsession may cause the person to perform reassurance behaviors, which are actions they take to make sure that other people are safe, like continuously calling someone on the phone.

Sexual obsessions often involve intrusive pornographic thoughts. This type of disturbing imagery may cause people to play mental games to distract themselves, like drawing pictures in their imaginations.

Religious obsessions tend to focus on the fear that the person isn’t doing what is morally right or the thought that he or she is going to be punished by God. Religious obsessions can also include uncontrollable, blasphemous thoughts in which the person curses God. In these cases, the person might perform a praying ritual or draw some type of religious imagery in a notebook.

Other obsessions include urges to do things that seem aggressive or very much out of the ordinary, like screaming at others for no reason. Afterward, the person might feel compelled to do something to relieve feelings of guilt or shame.

These are just a few examples of different types of obsessions. In all of these cases, the worries are highly unusual. They are not obsessional worries about common, daily occurrences, like paying the bills or getting to work on time. For each one of these obsessions, there are numerous types of compulsions, not just the ones listed here. In fact, a person’s obsessions and compulsions may not even be related to each other in any obvious way. A person may do anything after the intrusive thought to relieve himself or herself of anxiety. For example, a woman with a fear of contamination might obtain just as much relief from singing a song each time she feels dirty as she does from washing her hands. However, in all cases, the obsession and the action that follows it become habitual, time-consuming, and disturbing to the person who experiences them.

ARE THERE OTHER PROBLEMS RELATED TO OCD?

Many people with OCD also suffer with other related problems, such as depression,⁴ body dysmorphic disorder,^{5, 6} bipolar disorder,^{7, 8} phobias, panic disorder,⁹ alcohol problems, post-traumatic stress disorder,¹⁰ borderline personality disorder,^{11, 12} anorexia,¹³ depersonalization disorder,¹⁴ and trichotillomania.^{15, 16}

Another problem that is related to OCD is called obsessive-compulsive personality disorder.¹ Officially, this is considered a separate diagnosis, but in reality, it’s a very similar problem. Like someone with OCD, a person with an obsessive-compulsive personality disorder also has rigid internal demands for organization and precision, but these demands are usually much more widely spread throughout the person’s entire life. Someone with this problem may not appear as outwardly anxious as a person with OCD, but the person with the personality disorder still can’t complete a task unless an internal set of rules is followed. People with this type of personality disorder are sometimes described as collectors who never throw anything away or as misers who live in poverty while they hide their money for emergencies.

WHO IS AFFECTED BY OCD?

A 1996 report published by the World Health Organization and the Harvard School of Public Health¹⁷ found that OCD was the tenth leading cause of disability in the world among both physical and mental illnesses; plus, it’s the fourth most disabling mental health problem in the developed world. It’s estimated that almost 2 to 3 percent of adults in the United States suffer from OCD at some point in their lives.^{4, 18} By some estimates, that’s approximately three million adults in the United States alone.¹⁹

In adults, OCD is equally common in men and women.¹ However, research has shown that OCD begins earlier in males than in females. Typically, males develop OCD between the ages of six and fifteen, while females develop it later, between the ages of twenty and twenty-nine.¹

WHAT CAUSES OCD?

It’s estimated that 85 to 90 percent of all ordinary people experience intrusive thoughts and desires similar to those experienced by people with OCD.²⁰ So what allows one person to ignore the obsessive thoughts while another person develops ritualized compulsions in response to them? Although the exact causes of OCD are unknown, the disorder is believed to have both biological and social risk factors.

Research has shown that the chances of developing OCD are greater if someone in the person’s family has it.¹ The development of OCD can also be triggered by medical conditions, such as head injuries²¹ and epilepsy,²² as well as by the birth of a child, which can make either the mother or the father vulnerable to the disorder.²³ Researchers have also observed physical differences in the brains of people with OCD. The areas affected are associated with emotional memories,²⁴ voluntary movement,²⁵ motivation,²⁶ and learning.^{27, 28}

In a 1997 report in the journal Behaviour Research and Therapy, a group of OCD treatment experts concluded that people with OCD possess six unique qualities that might contribute to the development of the disorder.²⁹ These traits are the tendency to overestimate the danger of a situation, the inability to tolerate uncertainty, the belief that thoughts are controllable, the belief that every thought is important, the belief that perfection is both attainable and necessary, and the belief that the person has the power to create or prevent dangerous outcomes.

One leading developmental model theorizes that OCD behaviors are learned reactions for coping with anxiety. According to this behavioral model, compulsive actions quickly remove the anxiety that is caused by a person’s obsessive thoughts, so the person repeats those compulsive actions in the future. However, the anxiety only disappears for a short amount of time.³⁰ This temporary solution prevents the person from learning to tolerate the discomfort of anxiety and trains the person to use the compulsion each time he or she feels discomfort.

Interestingly, research has shed light on one of the reasons why it’s so hard to control unwanted thoughts. This research has demonstrated that the harder a person tries to avoid a thought or not think about something, the more the person will actually think about whatever it is that he or she is trying to forget.³¹

WHAT TREATMENTS ARE EFFECTIVE FOR OCD?

The U.S. National Institute of Mental Health has estimated that almost 1.5 million people seek treatment for OCD annually.³² However, most people with OCD wait as long as seven years before seeking help.⁹ This is very unfortunate, considering that there’s a very effective treatment for the disorder. The gold standard of treatment for OCD is a form of cognitive behavioral therapy called exposure and response prevention, or exposure and ritual prevention.³³ This treatment safely and systematically exposes a person to feared circumstances and then helps the person refrain from performing his or her compulsions. This results in an anxiety level that decreases naturally over time.

Researchers have found that this form of therapy can result in an 80 percent success rate in the treatment of OCD,^{34, 35} a result that’s often more successful than the use of medications.³⁵ Amazingly, the research also suggests that exposure and response prevention causes the same beneficial changes in brain chemistry that have been observed when patients use pharmaceutical treatments.^36-38 Often, it’s beneficial to include a person’s family members in the treatment of OCD, so that they can help the person overcome the disorder.³⁹

Antidepressants are often the first medications chosen to treat OCD, and they can be used successfully in conjunction with cognitive behavioral therapy.^40-42 Frequently used medications for OCD include clomipramine (Anafranil), fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and citalopram (Celexa).⁴³ (Click here for information about the use of medications.)

In severe cases of OCD where the person fails to respond to either cognitive behavioral therapy or medication, brain surgery is sometimes a successful option.^{44, 45} In a procedure called a cingulotomy, the surgeon makes a microscopic cut in the part of the brain that’s suspected of being involved with OCD. One study that assessed the success of cingulotomy procedures found that 32 to 45 percent of the patients showed long-term improvements.⁴⁶

COGNITIVE BEHAVIORAL THERAPY FOR OBSESSIVE-COMPULSIVE DISORDER

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for obsessive-compulsive disorder is generally composed of six steps:³⁰

Conduct an assessment and provide education
Create an inventory of the obsessions and compulsions
Create an exposure hierarchy
Engage in exposure and response prevention
Challenge and correct anxious thinking
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step of the cognitive behavioral treatment for OCD is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with OCD and not some other similar problem. This is often done with some type of obsessive-compulsive symptom scale and a detailed history of the person’s behaviors. The OCD symptom scale can also help people record their progress as the treatment proceeds.

Once people have been diagnosed with OCD, they should learn about the basic nature and causes of the disorder (as highlighted above). It’s also important to educate the person’s family and friends about the disorder in order to help them understand how they might be playing a role in maintaining the disorder, as well as how they might be able to help during the treatment. It’s also important for everyone involved to understand that CBT is an active form of treatment that requires the person with OCD and his or her loved ones to do work outside of the therapy session. (Click here for information on assessment and education for obsessive-compulsive disorder.)

2. Create an Inventory of the Obsessions and Compulsions

The next step is for the person to monitor his or her own behavior for obsessions and compulsions. It’s especially important for the person to record the observable rituals and compulsions performed to ease his or her anxiety, as well as the unobservable mental rituals (such as praying or singing) used to neutralize discomfort. From this self-monitoring, the person can create an inventory of his or her obsessions and compulsions. It’s not uncommon for a person to have several different kinds of obsessions, such as contamination obsessions and religious obsessions. The OCD treatment will usually target the most disturbing obsessions first. (Click here for information on making an inventory of obsessions and compulsions.)

3. Create an Exposure Hierarchy

As previously stated, the cognitive behavioral treatment for OCD is called exposure and response prevention, or exposure and ritual prevention. This treatment safely and systematically exposes a person to feared circumstances and then helps the person refrain from performing his or her compulsions. This exposure is done in a safe and systematic way and usually results in the person’s level of anxiety diminishing over time. The third step of the treatment, therefore, is to create a hierarchy, a graded list of feared situations that the person will expose himself or herself to, beginning with the least feared situation. The hierarchy is formed using the subjective units of discomfort scale (SUDS), which ranges from 0 to 100, with 100 being the most disturbing situation. For example, for a woman with a fear of germs and contamination, picking up a clean piece of paper might be a 30 on the SUDS scale, while taking out the dirty garbage is a 90. For the sake of the OCD treatment, this hierarchy should contain eight to ten feared situations that progressively increase in difficulty, beginning with an item with a SUDS level around 20 or 30. (Click here for information on making a hierarchy of feared situations.)

4. Engage in Exposure and Response Prevention

After the hierarchy has been constructed, the person should begin exposing himself or herself to feared situations with a SUDS level around 20 to 30. It’s very important that this be done without engaging in any compulsive behaviors to neutralize anxiety. The person should engage in each feared activity on the hierarchy long enough to clearly recognize that his or her anxiety level has decreased. For example, the woman with a fear of contamination might hold a piece of paper that’s been picked up off the floor for twenty minutes before she recognizes that her anxiety level has clearly decreased. Once each activity is successfully mastered, the person proceeds to the next level of difficulty, until all feared situations on the hierarchy are successfully mastered. (If the feared scene is dangerous or impossible to conduct in real life, such as talking with God about blasphemous thoughts, it’s also possible to conduct the exposure in the person’s imagination.)

During this process, it’s important for the person to record his or her thoughts and feelings before, during, and after the exposure, in order to keep track of how those thoughts and feelings change over time. It’s also important for the person to make predictions about what will happen before engaging in the exposure process. Many people predict that catastrophes will occur if they engage in feared situations, such as “I’ll become sick and die.” After the exposure is successfully completed, the person should reassess those predictions. By comparing what was expected to happen with what actually did happen, people struggling with OCD learn to monitor their cognitive processing. They also begin to recognize that they habitually overestimate the threat of certain situations and learn to reassess their coping abilities. (Click here for instructions on performing exposure and response prevention techniques.)

In fact, it’s often very helpful early in the treatment for the person to create a list of coping thoughts to stay motivated throughout treatment. “I’ve survived situations like this in the past,” is one example of a coping thought.

5. Challenge and Correct Anxious Thinking

As the exposure and response prevention treatment continues to make progress, the next step of the cognitive behavioral treatment for OCD is to challenge and correct anxious thoughts. These thoughts are often the cause of OCD. At the most observable level are automatic thoughts. These are critical thoughts that people think and say to themselves that sabotage feelings of security and happiness. Two examples of automatic thoughts might be “My thoughts are dangerous” and “I’m unable to cope, so why bother trying?” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels anxious or fearful. (Click here for information on identifying automatic thoughts.)

Much of the cognitive behavioral treatment for OCD will be spent identifying and reevaluating these errors in thinking. This can be done with the use of a thought record. The thought record helps the person with OCD look for evidence that supports and contradicts these thoughts and then, most importantly, it helps the person create a more balanced thought. For example, if the person struggling with OCD had the thought “I’m unable to cope, so why bother trying?” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.

The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that perpetuate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. (Click here for information on identifying cognitive distortions.)

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person with OCD find a new, more balanced thought and ease feelings of anxiety and fear. In this example, perhaps a more balanced thought would be “I might not be able to cope as well as I’d like to, but I’m still able to handle most situations pretty well.” And instead of feeling excessively anxious, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less anxious, say only a 5 out of 10. (Click here for instructions on using a thought record.)

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to anxiety and OCD. These core beliefs, often called schemas, include thoughts like “I’m incompetent,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques. (Click here for instructions on challenging core beliefs.)

Other cognitive techniques that are often helpful in treating OCD include reestimating the true probability of danger in a situation, reassessing the level of responsibility a person actually has in a feared situation, and challenging the person’s need for certainty. (Click here for instructions on other cognitive techniques.)

6. Prevent Relapse

Finally, the last step of the cognitive behavioral treatment for OCD is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning OCD in order to take steps to prevent relapse. (Click here for instructions on preventing relapse of OCD.)

ACCEPTANCE AND COMMITMENT THERAPY FOR OBSESSIVE-COMPULSIVE DISORDER

Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.

ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. A person can’t throw them out the same way he or she gets rid of an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.

The ACT treatment for obsessive-compulsive disorder generally includes eight steps:⁴⁷

Educate about OCD, anxiety, and ACT
Develop creative hopelessness
Clarify values
Commit to taking action
Develop acceptance
Focus on contact with the present moment
Utilize cognitive defusion
Stay committed to values and actions

1. Educate About OCD, Anxiety, and ACT

The initial step of the ACT treatment for obsessive-compulsive disorder is to educate the person about OCD and the nature of anxiety. It’s especially important for the person to understand the nature of anxiety from an ACT point of view. According to this treatment, anxiety and fear themselves are not the causes of OCD. Rather, it’s the person’s avoidance of anxious and fearful emotions and thoughts that make OCD an overwhelming problem. Starting with the early stages of treatment, it’s also important for people to understand that ACT is an active, participatory treatment designed to help them live a more fulfilling life, not necessarily a “happier” one. (Click here for more information about acceptance and commitment therapy.)

2. Develop Creative Hopelessness

In order to develop what ACT calls “creative hopelessness,” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with fear and anxiety. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of fear and anxiety, which can never be successful. For example, a man who attempts to control his fear of contamination by excessively washing his hands actually develops a worse problem, as does a woman who tries to avoid her anxious feelings about being imperfect by continually checking her actions over and over again. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with fear and anxiety. (Click here for instructions on how to develop creative hopelessness.)

3. Clarify Values

ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. Clarifying and establishing what a person values can often help that person live a more fulfilling life, despite having occasional feelings of anxiety or fear. Values are the elements of life that give it meaning and importance, like “maintaining a loving relationship with my spouse or partner” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a loving relationship and still have a loving relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values. (Click here for instructions on how to clarify and establish values.)

4. Commit to Taking Action

After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a person’s value is to be an active member of her community, she might list a number of different goals to fulfill that value, such as “attend community meetings twice a month.” This is something that can be completed and thereby create a sense of valued living. The ACT treatment for obsessive-compulsive disorder includes development of skills and goals that lead to taking committed action. (Click here for instructions on how to commit to taking action.)

5. Develop Acceptance

In ACT, learning to accept feared situations and anxious emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.

In order to cultivate acceptance, people are encouraged to experience the anxious emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded. (Click here for instructions on how to develop acceptance skills.)

6. Focus on Contact with the Present Moment

Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling fear and anxiety. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body. (Click here for instructions on how to develop present-focused mindfulness skills.)

7. Utilize Cognitive Defusion

Cognitive defusion is a mindfulness technique that helps people observe their anxious and fearful thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with OCD to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that OCD could worsen over time if a person were to follow or believe every thought and emotion that arose.

Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings. (Click here for instructions on how to develop cognitive defusion skills.)

8. Stay Committed to Values and Actions

In order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past. (Click here for instructions on how to stay committed to values and actions.)

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